Coroner's Finding: Mountford, Raymond Malcolm Edward

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INQUEST INTO THE DEATH OF RAYMOND MALCOLM EDWARD MOUNTFORD [2025] SACC 38 Inquest Findings of her Honour Deputy State Coroner Roper 8 December 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of a man who died while serving a sentence of imprisonment for criminal offences. The inquest explored the adequacy of his medical treatment in custody.

Held:

1. Raymond Malcolm Edward Mountford, aged 82 years of Northfield, died at Yatala Labour Prison on 2 February 2023 as a result of ischaemic and hypertensive heart disease.

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MR G DUDZINSKI Hearing Date/s: 12 November 2025 Inquest No: 35/2025 File No/s: 0287/2023

INQUEST INTO THE DEATH OF RAYMOND MALCOLM EDWARD MOUNTFORD [2025] SACC 38 Reason for inquest Raymond Malcolm Edward Mountford was 82 years old when he died on 2 February 2023 at the Yatala Labour Prison from natural causes.

Mr Mountford had been lawfully incarcerated since 18 September 2008, when he was admitted into custody on remand. From that time, and until 29 October 2021, Mr Mountford was sentenced to numerous lengthy terms of imprisonment for serious sexual offences against children spanning 1973 to 2004.

As Mr Mountford died in custody, an inquest into the cause and circumstances of his death was mandatory.1 Who was Mr Mountford?

Mr Mountford was born on 30 April 1940 in England. In 1945 he migrated to Australia with his family and initially lived in Victoria. Mr Mountford described a difficult childhood marred by sexual abuse. When he was around 14 years old, his mother returned to England to care for her sick father. Mr Mountford never saw her again. She passed away in 1998.

Mr Mountford left his Catholic high school prior to completion of Year 7 and entered the workforce. His first job was as a filing clerk. Following that, he worked in music stores and as a music teacher. Mr Mountford was married twice and fathered six children.

What was Mr Mountford’s medical condition prior to incarceration?

From the age of about 45 years, Mr Mountford was in receipt of a Disability Support Pension due to a diagnosis of diabetes, and unspecified heart and kidney issues. At the time of his incarceration in 2008, Mr Mountford was 68 years old. He was known to suffer from type 2 diabetes mellitus, angina and high cholesterol.

How was Mr Mountford’s health managed while he was in custody?

From 13 September 2019 Mr Mountford resided in the Yatala Labor Prison, which is a public prison. The South Australian Prison Health Service (SAPHS) is responsible for provision of health care services to people in custody within the public prisons of South Australia.

Dr Thomas Turnbull, then Medical Director of the SAPHS, furnished an affidavit in which he summarised Mr Mountford’s medical management in custody. He stated that Mr Mountford’s medical history included: Ischaemic heart disease a.

Chronic obstructive pulmonary disease b.

Type 2 diabetes mellitus c.

1 Coroners Act 2003, section 21(1)(a)

[2025] SACC 38 Deputy State Coroner Roper Cerebrovascular disease d.

Dementia e.

Hypertension f.

Hypercholesterolaemia g.

Chronic kidney disease (stage 4) h.

Benign prostate hypertrophy i.

In 2015 Mr Mountford experienced a cardiac arrest, which led to a diagnosis of severe triple vessel coronary artery disease. Mr Mountford underwent triple coronary artery bypass grafting surgery.

Mr Mountford was administered many medications for his multiple comorbidities throughout his time in custody. Changes were made to these medications in response to regular blood tests and clinical reviews.

At the time of his death, Mr Mountford was living in the aged care section in the infirmary of the Yatala Labour Prison. He was housed with three other inmates and had no reported enemies within his unit.

Mr Mountford regularly consulted with medical staff during his time in the aged care section of the infirmary, with a review occurring almost fortnightly. Throughout 2021 and 2022, Mr Mountford’s medical consultations were primarily in relation to his chronic renal failure and urinary tract infections.

He was also diagnosed with mild fluid overload secondary to left heart failure on 8 September 2021. He was prescribed the diuretic medication furosemide and advised to monitor his blood pressure.

On 29 November 2021, Mr Mountford’s medications were reviewed, and a decision was made to cease furosemide and commence spironolactone.

On 12 January 2022, Mr Mountford was diagnosed with hyperkalaemia (high potassium) secondary to chronic renal failure. He was prescribed Resonium, a medication to lower his potassium. During this consult, Mr Mountford completed a 7 Step Pathway in which he recorded his end of life wishes. This included a direction that he did not want to be resuscitated following any cardiac arrest.

Mr Mountford underwent a further blood test that afternoon which revealed that his potassium level had increased further. Accordingly, and appropriately, he was transported to the Modbury Hospital via ambulance.

Mr Mountford was returned to Yatala with advice to cease spironolactone and to recommence furosemide, presumably as this medication is used in the treatment of both heart failure and hyperkalaemia.

The medication change appeared to be effective, as on 14 January 2022 Mr Mountford’s blood test results confirmed that his potassium levels had decreased. Mr Mountford also advised the doctor that he had been eating three bananas a day. He was advised to reduce this to one and a half per day.

[2025] SACC 38 Deputy State Coroner Roper In March 2022, Mr Mountford began suffering from hallucinations. Following a consult on 25 March 2022, arrangements were made to transport Mr Mountford to the Royal Adelaide Hospital, where he was admitted from 26 to 31 March 2022.

Medical imaging was performed to identify the cause of his hallucinations, including an MRI of the head and a CT brain scan. The findings were consistent with known prior infarcts and dementia. Mr Mountford was commenced on risperidone at night with reportedly good effect.

On 8 April 2022, Mr Mountford reported no further hallucinations. He continued fortnightly consults at the infirmary throughout 2022, and his health appeared to be stable, except for ongoing urinary symptoms related to his chronic kidney disease.

The sudden death of Mr Mountford On 2 February 2023, Mr Mountford was sighted by a correctional officer at 8am. There was nothing about Mr Mountford’s presentation that raised any concern.

At 8:17am the cells in the aged care section were opened and Mr Mountford, along with other prisoners, gathered in a communal area. He walked around utilising his walking frame and consumed breakfast.

At about 10:30am, Mr Mountford went to the nurses’ station for monitoring of his blood sugar levels, which was part of his usual routine. The result was within his ordinary range.

The nurse had a brief conversation with Mr Mountford about his welfare and he said that he felt fine, and ‘don’t need nothing’.

At around 11:20am, Mr Mountford was secured in his room with his cell mates and lunch was provided. The correctional officer enquired with Mr Mountford at this time if he was alright and Mr Mountford replied ‘yes’.

At around 1:22pm the correctional officer unlocked Mr Mountford’s cell. She noticed that while Mr Mountford’s cell mates were all asleep, Mr Mountford ‘looked different’.

He was laying on his back, his mouth was open, and he appeared to be grey in colour.

She called to Mr Mountford multiple times. He did not respond.

The correctional officer called for nursing assistance and initiated a code black at about 1:23pm. Mr Mountford’s cell mates were removed from the cell, and medical staff attended to Mr Mountford. There was no attempt at resuscitation made, in accordance with his expressed wishes. Mr Mountford was pronounced life extinct at 1:36pm.

What was the cause of Mr Mountford’s death?

A post-mortem examination was conducted by forensic pathologist, Dr John Gilbert. His findings included severe triple vessel native coronary artery atherosclerosis and cardiomegaly. A retro nasal swab taken at autopsy tested positive for coronavirus.

Dr Gilbert concluded that the cause of Mr Mountford’s death was ischaemic and hypertensive heart disease. He found no evidence of significant complications of coronavirus infection such as viral or bacterial pneumonia, although he noted that the infection could have been an aggravating factor in the death of Mr Mountford. In relation

[2025] SACC 38 Deputy State Coroner Roper to Mr Mountford’s coronary artery bypass grafting surgery, Dr Gilbert observed that the grafts were patent, indicating that the procedure had achieved its intended outcome.

Dr Gilbert found no injuries or markings that would indicate the involvement of another person in the death of Mr Mountford. This is consistent with the observations of the investigating officer, who did not observe any signs of violence or struggle at the scene, nor any injuries to Mr Mountford’s body.

I find that the cause of Mr Mountford’s death was ischaemic and hypertensive heart disease. I am satisfied that no third party contributed to his death, which was the result of natural causes.

Conclusion I find that Mr Mountford received regular and appropriate medical care in custody.

Although his death occurred suddenly, it was not unexpected given his multiple comorbidities, particularly his chronic heart disease.

I make no recommendations.

Keywords: Death in Custody; Prison; Natural Causes